NDP

HOW TO CLAIM

National Dental Plan

Dental Claim Form Dental Claim Form

THIS PAGE TO BE COMPLETED BY PATIENT

1. Complete the personal details below. 2. Ask the Dentist or Receptionist to complete the back of this form. Attach a receipt for the cost of your treatment. or alternatively: Obtain an itemised receipt, attach it to the claim form and ask the Dentist or Receptionist to stamp the form. 3. Send the form and receipt to Claims Assistance (UK) Ltd, Ibex House, Minories, London EC3N 1DY Tel: 020 7488 9880. Please note: Claims without proof of payment cannot be processed. Claims must be submitted within 90 days of completion of the last treatment in any course. Reimbursement will be made in accordance with your policy summary.

MEMBERS DETAILS

Name Title (Mr/Mrs/Miss, etc) Date of birth Home address, including postcode

Name of employer NDP membership number (if known) PATIENTS DETAILS (IF DIFFERENT FROM ABOVE)

Name Title (Mr/Mrs/Miss, etc) Date of birth DECLARATION to be signed by Patient (or by Member if Patient is under 18 years of age) I declare that the information provided on this form is, to the best of my knowledge, true and complete and authorise NDP to obtain any information relating to this claim from my dentist. I confirm that I give consent within the provisions of the Data Protection Act 1998 for NDP or its agent to process my personal data, including medical information, for the purposes of administering the dental plan.

Patients signature Daytime telephone number PAYMENT If you wish to receive payment by cheque, please tick If you wish to receive payment by BACS, please tick Account name Account number E-mail address for remittance advice and complete details below Sort code

Date

Roll number (if applicable)

National Dental Plan Limited, Ibex House, Minories, London EC3N 1DY Tel: 020 7480 7201 Fax: 020 7481 2842 E-mail: ndp@nationaldental.co.uk Web: www.nationaldental.co.uk National Dental Plan Limited is authorised and regulated by the Financial Services Authority

THIS PAGE TO BE COMPLETED BY DENTIST

NHS OR PRIVATE TREATMENT NHS TREATMENT CHARGED BY BAND DATE OF TREATMENT UNITS OF TREATMENT CHARGE FOR INTERNAL USE ONLY

NHS NHS NHS NHS

Band 1 Band 2 Band 3 Emergency treatment

TREATMENT CHARGED INDIVIDUALLY EXAMINATIONS

Basic examination (Max 2 per policy year) Extensive examination (Max 1 per policy year) Full case assessment (Max 1 per policy year)
X-RAYS

Small x-ray (Max 4 per policy year) Medium x-ray (Max 4 per policy year) Panoral x-ray (Max 1 per policy year)
SCALINGS

Simple scaling (Max 2 per policy year) Complex scaling (Max 2 per policy year)
FILLINGS

Silver filling Silver filling Silver filling

1 surface 2 surfaces 3 surfaces

White filling 1 surface White filling 2 surfaces White filling 3 surfaces Pin for filling
ROOT TREATMENTS

Root canal Root canal Root canal Apicectomy

EXTRACTIONS

Incisor / Canine Premolar Molar

Extraction Surgical extraction

VENEERS AND INLAYS

Veneer (Prior approval required before treatment if more than 1 per policy year) Inlay (Prior approval required before treatment if more than 1 per policy year)
CROWNS AND BRIDGES

Crown Post for crown Conventional bridge (Any number of units) Adhesive bridge (Any number of units) Re-fix or re-cement crown Re-cement bridge
DENTURES

Acrylic upper or lower denture Acrylic upper and lower denture Chrome upper or lower denture Chrome upper and lower denture Repair or reline denture
MISCELLANEOUS TREATMENTS

Mouthguard Anaesthetic (Per visit) Emergency charge Overnight hospital stay (Max 1 per policy year) Orthodontics (Children only annual maximum) Other treatment (Please specify)
TOTAL CHARGE

Yes / No
DENTISTS STAMP

Is the treatment as a result of an accident/sports injury? Dentists telephone number